Summary At 0933:44 eastern daylight time, an Air Canada Airbus A320, registration C-FDRP (FlightACA513), was cleared for take-off on Runway24 of Qubec/Jean Lesage International Airport, Quebec. Sixteen seconds later, the controller instructed the Pro Aviation Cessna172, registration C-FGIM, to taxi to position on Runway30. At 0934:50, the controller saw the Cessna172 roll and take off toward the intersection of runways30 and24. Immediately, the controller twice ordered the AirbusA320 to abort take-off. Seeing that the AirbusA320 was continuing its take-off run, he ordered the Cessna172 three times to turn left. None of these attempts to contact the pilots were successful because the transmit function of the airport control radio had been previously disabled by the controller in an attempt to improve radio reception quality. Approximately 1000feet from the intersection, at rotation speed, the captain of the Airbus A320 saw the Cessna; he immediately ordered the co-pilot to not take off until they had crossed Runway30. The Cessna flew over the Airbus A320 about 200feet above it, at the intersection of the two runways. There were no injuries. Ce rapport est galement disponible en franais. Other Factual Information ACA513, an Airbus A320 with 2flight crew, 4cabin crew and 140passengers, was on a scheduled instrument flight from Qubec/Jean Lesage International Airport, Quebec, to Toronto, Ontario. At 0933:44 eastern daylight time,1 ACA513 was cleared for take-off on Runway24. The captain, responsible for communicating with air traffic control, was bilingual. Since the co-pilot was unilingual Anglophone, the crew spoke to the controller in English. The Pro Aviation Cessna172 was on a visual flight rules flight from Qubec/Jean Lesage International Airport to Trois-Rivires Airport, Quebec, with one pilot and one passenger on board. At 0934, the controller instructed the Cessna172, which was on taxiway Charlie, to taxi to position on Runway30. The instructions were given to the Cessna172 pilot in French. The crew of ACA513 did not hear the controller talking to the pilot of the Cessna172. Figure1. Flight path of the aircraft At 0934:34, a Cessna Citation in the parking area called the Qubec ground controller. The strength of the transmission was low and the pilot was practically inaudible. To improve reception quality, the controller deactivated the air frequency transmit button. He then realized that the Cessna172 had started its take-off roll without clearance and was abeam of taxiway Bravo. Immediately thereafter, the controller twice attempted to instruct the crew of ACA513, which was rolling at a speed of 58knots abeam of taxiway Alpha, to abort take-off. After realizing that the Airbus A320 was not slowing down, the controller then attempted to instruct the pilot of the Cessna172 three times to initiate an immediate left turn. Neither the instruction to ACA513 nor to the Cessna172 could be heard on the air frequency, because the air frequency transmit button had been deactivated. At 0935:20, about 1000feet from the intersection of runways24 and30, when the AirbusA320 had reached its rotation speed (146knots), the captain saw the Cessna172 in flight on a converging track. He immediately ordered the co-pilot, who was at the controls, to delay the rotation and to not take off until they had crossed Runway30. Radar data show that the Cessna172 flew over the AirbusA320 with 200feet of clearance above the intersection of the two runways. The weather was suitable for visual flight. The winds were calm, there were no clouds below 5000feet, visibility was over six miles and there was no precipitation. The automatic terminal information service (ATIS) message indicated that intersecting runways were active. The pilot of the Cessna was qualified for the flight in accordance with existing regulations. He had held a private pilot licence since 1981and had 83flying hours. In2002, he had retaken private pilot training at Pro Aviation because he had not flown for over two years. He passed an examination at the end of the training course. The pilot had made 10flights in 2003and 3flights in 2004before the incident. Six of those flights were made with a Pro Aviation instructor. He thought that the instruction to taxi to position on the runway included clearance to take off. The pilot, who understood English, had not paid attention to the messages between the tower and the Airbus crew. The controller, who was also the duty supervisor, began his career in1991. He had been a controller at the Qubec/Jean Lesage International Airport since2000, and was made a shift supervisor in March2004. His duties as a supervisor included the following: ensuring technical services were advised of any equipment defects as reported by personnel on duty; assigning work positions; managing work schedules; authorizing and coordinating the opening and closing of the coordinator's position; advising NAV CANADA management of all non-routine operations in accordance with the requirements set out in the Air Traffic Control Manual of Operations (ATC MANOPS) and the Air Traffic Services Administrative and Management Manual (ATSAMM); and evaluating personnel skills. The supervisor received ATS trainer on-the-job training in 1995and2002. That training consisted mainly of improving interpersonal skills and teaching techniques. There are no courses for simulating an emergency or equipment failure. According to his peers, he had above-average skills and knowledge as a controller. The NAV CANADA ATS Operational Proficiency Program delegates, to immediate supervisors or a qualified delegated evaluator, the responsibility to ensure that controllers' communication skills meet the established standards. All supervisors are automatically recognized as qualified delegated evaluators. The evaluation of the supervisor's communication skills, as for all supervisors in the Qubec control tower, is done by another supervisor in the unit. The supervisor's most recent operational communication skills check was carried out on 28April2004. The delegated evaluator, also a Qubec tower supervisor, noted 2errors in 80transmissions. When the incident ATC communications recording was reviewed, a number of phraseology errors were noted. As a result, the TSB examined the recording of the supervisor's most recent operational communications skills check. That review revealed many instances of incorrect phraseology not noted by the delegated evaluator. The Qubec control tower has five operating positions. The ground, air, and coordinator control positions can be combined on one console. The ATC operational support specialist and supervisor positions are complementary to operations. According to the ATSAMM and the Qubec control tower manual administrative instructions, the supervisor can give personnel breaks by combining operating positions, provided that the existing and forecast volume of work allows and that employees can be called back promptly. On the day of the incident, two controllers, one supervisor and one operational support specialist were available for the 0700 shift. At approximately 0645, the supervisor completed the position log. The positions were assigned as follows: At 0700, when the positions were combined, the duty controller selected the appropriate radio controls to transmit on the ground and air frequencies at the same time. At 0800, the supervisor changed the assignment of the controller tasks as follows: At the time of the incident, the supervisor, who was seated at Air1 position, was working the positions of air and ground control combined; the two controllers were on break at the time. One of them was in the control tower cabin, available if needed; he was not assigned any tasks and was not observing traffic. The hourly aircraft movements (departures, arrivals and overflights) logged at the Qubec Airport on 13June2004 were: 9movements between 0700 and 0800, 9movements between 0800 and 0900, and 15movements between 0900and 1000 (7between 0900 and the time of the incident). NAV CANADA assesses the traffic in each of the 0700, 0800 and 0900hourly periods as light. The procedures for controlling air traffic are set out in the NAV CANADA ATC MANOPS. If an aircraft is number1 in the departure sequence, the controller can instruct it to taxi to position on the runway without specifying that it must wait.2 The pilot must wait on the runway for take-off clearance. The ATC MANOPS does not define number1 for take-off. In this occurrence, the controller did not ask the Cessna172 to wait after instructing it to taxi to position on Runway30. The controller considered that the Cessna172 was number1 in the departure sequence because the AirbusA320 had received clearance to take off. The controller may clear several aircraft to taxi to position for take-off on intersecting runways provided that the aircraft receive a departure sequence number when a departing aircraft is not number1 for take-off; the aircraft that is not number1 is instructed to Wait and inform the aircraft of the reason for the delay3; all aircraft are visible to the airport controller; and traffic information is given to the second and subsequent aircraft in the departure sequence4. During taxi operations, the controller must receive an accurate read back after issuing an instruction to an aircraft or vehicle to hold or hold short of a runway or taxiway.5 Section4.2.5 of RAC (Rules of the Air and Air Traffic Services) of the Aeronautical Information Publication (A.I.P.Canada) states that, to enhance the protection of active runways and to prevent runway incursions, taxi authorizations that contain the instructions HOLD or HOLD SHORT shall be acknowledged by providing a read back or repeating the hold point. ATC MANOPS does not explicitly include the requirement to obtain a read back of a taxi to position and wait instruction. The investigation has identified similarities between the phraseology used by controllers in Canada and the United States to clear an aircraft onto a runway to hold or wait, and the International Civil Aviation Organization (ICAO) phraseology used to clear an aircraft to hold short of a runway (seeTable1). Although this issue was not shown to have operated in this occurrence, these similarities have the potential to degrade the safety of the air transportation system. The use of the word position in Canada and the United States is associated with a position on a runway, whereas the same word is used in ICAO phraseology to indicate a holding position short of the runway. North American crews operating in parts of the world where ICAO phraseology is used may confuse the term taxi to holding positionwith taxi to position. This confusion could result in a crew taxiing onto an active runway when they had been cleared to a point short of the runway. In a letter dated 25April2003, ICAO stated that flight crew from States unfamiliar with ICAO phraseology have misunderstood TAXI TO HOLDING POSITION, as meaning TAXI TO POSITION AND HOLD, and proceeded to line up on the runway. These similarities in phraseology have the potential for catastrophic consequences. The controller must separate a departing aircraft from an aircraft using an intersecting runway or a non-intersecting runway where the flight paths intersect by ensuring that the departing aircraft does not begin its take-off roll until the preceding departing aircraft has passed the intersection, crossed the take-off runway, or turned to avoid any conflict.6 A few months before this incident, technical issues led NAV CANADA to change the Qubec tower air frequency twice. Controllers subsequently noticed on occasion that a brief parasite noise momentarily interfered with the tower frequencies. However, this anomaly was not reported to technical services or entered in the deficiency log as it should have been. A check of the tower radios after the incident revealed no deficiency. Also, it was established that the deactivation of the air transmitter had no effect on the reception of the ground frequency. Review of the ATC tape revealed that, in the 15minutes preceding the incident and in the 5 minutes after the incident, 62of the 136messages on the air and ground frequencies were sent by the controller. Strict application of the ATC MANOPS standards revealed a substantial number of deficiencies in standard phraseology, including omission to identify the station, incorrect information sequence, omission of information, incorrect call-sign on a take-off clearance, and incorrect phraseology and terminology to cancel the take-off clearance of the AirbusA320 and the Cessna172. Qubec Airport is a controlled airport with two runways: Runway 06/24 is 9000feet long and 150feet wide, and Runway12/30 is 5700feet long and 150feet wide. The runways intersect 5800feet from the threshold of Runway24 and 4300feet from the threshold of Runway30. Because the airport facilities are located between the two runways, a pilot on Runway24 cannot see the threshold of Runway30 until the aircraft is approximately 2900feet from the threshold of Runway24. The control tower is to the east of the runway intersection. At the time of the incident, the supervisor was seated at the Air 1 position; Runway24 was in front of him and was fully visible. To the controller's left, the work consoles obstruct part of Runway30 when the controller is seated. To see the threshold up to taxiway Bravo, the controller must rise slightly. Following the evaluation of the unit in June2004, NAV CANADA concluded that the controllers are able to see all taxiways, all runways and all runway approaches without rising or leaving their main air-ground supervisor position. In June 2003, Transport Canada performed an audit of the air traffic services at the Qubec tower. Transport Canada noted that several reports on operational communications skills contained no comments as to the quality of phraseology. Also, the audit team noted that the bank of questions and the knowledge verification tests for the qualification maintenance program contained very few critical questions in comparison with the number of ordinary questions. Transport Canada found that the Qubec tower was in compliance with established standards. A corrective action plan to correct the above-noted non-safetyrelated deficiencies proposed by NAV CANADA was accepted by Transport Canada. On a review of the Qubec tower from 14to 18June2004, NAV CANADA identified the following deficiencies among others: some anomalies relating to communications procedures; control personnel did not comply at all times with the ATC MANOPS requirements by not informing all aircraft of traffic, by not ensuring that read backs were correct, and by not informing aircraft of the reason for the delay after clearing them to taxi to position and instructing them to wait; and some entries resulting in aviation occurrence reports did not indicate whether the report had been forwarded. A memorandum from NAV CANADA dated 24August2004 indicates that all deficiencies identified have been corrected or were in the process of being corrected. The investigation found that, at the Qubec tower, there were some deviations from operating standards and that some controllers were not fully familiar with the radio system and some ATC MANOPS procedures: some controllers do not report unauthorized take-offs; some controllers do not know or do not fully know the functions of the buttons on the radio console in the tower; according to some controllers, pilots are not required to read back instructions to taxi containing the instruction WAIT; and inconsistency with regard to the interpretation as to when an aircraft becomes NUMBER 1 in the traffic sequence. According to current regulations,7 NAV CANADA must report all failures to comply with Canadian Aviation Regulations (CARs) associated with the use of an aircraft. However, the investigation revealed that unauthorized take-offs were not all reported by the Qubec tower. NAV CANADA policy and direction require that all aviation occurrences be reported. The reasons given for not reporting this type of occurrence are as follows: the possibility that the report would be prejudicial to a new pilot or a pilot with little experience; the low probability that an air safety investigation would be initiated; air safety was not compromised; and listening to ATS tapes might reveal errors of phraseology. Transport Canada's Civil Aviation Daily Occurrence Reporting System (CADORS) database was consulted to determine the frequency of take-offs without clearance in Canada. The information in CADORS is summary in nature and is generally not validated. Over the five years preceding the incident, the following unauthorized take-offs were reported: 44 occurrences were reported with no details as to the type of ATC clearance or instruction; 29 occurrences were reported with clearance to taxi to position on the runway and wait; it is not specified whether the pilot read back the clearance or was asked to do so; and 20 occurrences were reported with the instruction to taxi to position on the runway without specifying whether the pilot was instructed to hold. No occurrences of take-offs without a clearance were reported at the Qubec Airport during this five-year period.